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PLAN INFORMATION
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Maximum Limits
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$50,000, $100,000, $500,000, $1,000,000, $2,000,000 (Patriot International only)
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Individual Deductible options
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$0, $100, $250, $500, $1,000, $2,500
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Coinsurance - for treatment received outside the U.S.
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Company pays 100%
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Coinsurance - for treatment received within the U.S.
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In the PPO Network - Company pays 100%
Out of the PPO Network - Company pays 80% of eligible expenses up to $5,000, then 100%
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Incidental Trips to Home Country
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14 consecutive days maximum limit
Insured person’s country of residence is not the U.S.
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Incidental Emergency Coverage in the U.S. (Patriot International Only)
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14 consecutive days maximum limit. Available only for a covered emergency medical evacuation, or an emergency injury or illness that manifested during travel through the United States to or from the Host Country.
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Pre-Certification
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Fifty percent (50%) reduction of Eligible Medical Expenses if pre-certification provisions are not met.
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Hospital Room and Board
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Average semi-private room rate up to the maximum limit. Includes nursing service.
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Intensive Care
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Up to the maximum limit
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Surgery
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Up to the maximum limit
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Physician Visits
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Up to the maximum limit
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Diagnostic Procedures
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Up to the maximum limit
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Prescription Medication
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Up to the maximum limit
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Home Health Care
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Up to the maximum limit
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Emergency Local Ambulance
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Up to the maximum limit
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Durable Medical Equipment
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Up to the maximum limit
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Emergency Dental Treatment
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$300 maximum limit due to accident or unexpected pain to sound natural teeth.
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Traumatic Dental Injury
Treatment at a hospital due to an accident
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Up to the period of coverage maximum limit
Subject to deductible and coinsurance
Additional treatment for the same injury rendered by a dental provider will be paid at 100%
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Emergency Medical Evacuation
Must be approved in advance and coordinated by the company
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$1,000,000 maximum limit. Not subject to deductible.
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Emergency Reunion
Must be approved in advance by the company
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$50,000 maximum limit. Not subject to deductible.
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Return of Mortal Remains or Cremation/Burial
Must be approved in advance by the company
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$50,000 maximum limit for return of mortal remains or ashes to country of residence, or $5,000 maximum limit for cremation or local burial at the place of death. Not subject to deductible.
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Return of Minor Children
Must be approved in advance by the company
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$50,000 maximum limit. Not subject to deductible.
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Political Evacuation
Must be approved in advance by the company
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$10,000 maximum limit. Not subject to deductible.
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Natural Disaster
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$250 per day and maximum limit of five days for accommodations. Not subject to deductible.
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Terrorism
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Up to $50,000 lifetime maximum. Not subject to deductible.
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Acute Onset of a Pre-existing Condition - Medical (Patriot International Only)
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U.S. citizen up to age 65 with primary health plan: Up to maximum limit.
U.S. citizen up to age 65 without primary health plan: $20,000 lifetime maximum.
U.S. citizen age 65 to age 70: $2,500 lifetime maximum.
Non-U.S. citizen up to age 70: Up to maximum limit or $500,000 - whichever is lower.
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Acute Onset of a Pre-existing Condition - Emergency Medical Evacuation (Patriot International Only)
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Up to age 65: $25,000 maximum limit
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Urgent Care
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$25 co-pay. Co-pay is not applicable when the $0 deductible is selected.
Not subject to deductible
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Walk-in Clinic
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$15 co-pay. Co-pay is not applicable when the $0 deductible is selected.
Not subject to deductible
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Physical Therapy
Medical order or treatment plan required
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Up to the maximum limit
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Hospital Emergency Room: International
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Deductible waived
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Hospital Emergency Room: United States
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Injury not subject to emergency room deductible
Illness: Subject to a $250 deductible for each emergency room visit for treatment that does
not result in direct inpatient hospital admission
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Hospital Indemnity
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Up to $100 per overnight up to a maximum of 10 overnights. Not subject to deductible.
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Common Carrier Accidental Death
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$50,000 per insured person and $250,000 Maximum limit per lifetime and per Family. Not subject to deductible.
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Accidental Death & Dismemberment
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$25,000 principal sum. Not subject to deductible.
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Identity Theft Assistance
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Up to $500. Not subject to deductible.
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Trip Interruption
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Up to $5,000. Not subject to deductible.
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Lost Luggage
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Up to $50 per item; maximum of $250. Not subject to deductible.
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